Inspection on 31/01/06 for Stambridge Meadows

This inspection was carried out on 31st January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stambridge Meadows 01/04/10

Stambridge Meadows 05/10/09

Stambridge Meadows 16/04/09

Stambridge Meadows 09/10/08

Stambridge Meadows 04/05/08

Stambridge Meadows 09/01/08

Stambridge Meadows 23/08/07

Stambridge Meadows 15/01/07

Stambridge Meadows 03/05/06

Stambridge Meadows 28/09/05

Stambridge Meadows 01/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stambridge Meadows Stambridge Road Great Stambridge Rochford Essex SS4 2AR Lead Inspector Michelle Love Unannounced Inspection 31st January 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stambridge Meadows Address Stambridge Road Great Stambridge Rochford Essex SS4 2AR 01702 258525 01702 258229 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ashbourne (Eton) Limited Ms Lorraine Louise Reynolds Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49), Terminally ill (2) of places Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Terminal illness to include persons over the age of 55 Date of last inspection 28th September 2005 Brief Description of the Service: Stambridge Meadows is a care home with nursing for up to 49 older people. The home also has a terminal illness category and can care for up to two residents. The home is situated approximately three miles from Rochford Town Centre and is set in pleasant country surroundings. The home has 40 single bedrooms, 33 with en-suite facilities and 5 double bedrooms, 2 of which have en-suite facilities. The home has three lounges, one of which has a designated dining area. The home also benefits from a visitors lounge area on the ground floor. The spacious grounds are well maintained, with several paved areas. The home is in good decorative order with high quality accommodation for residents. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out by Michelle Love and Carolyn Delaney. The inspection took place over 10.5 hours and totalled 21 hours. At this visit a tour of the premises took place throughout different times of the day, care plans/risk assessments/healthcare records and staff employment files were inspected. At the time of the visit the registered manager was absent from the care home. The inspection was conducted with the home’s care manage and several members of care staff, residents and relatives were spoken with. This is the home’s second inspection since Ashbourne Healthcare took over the home’s registration. Recently the home has been taken over by Southerncross Healthcare. The Commission for Social Care Inspection is very concerned at the number of statutory requirements and recommendations not actioned following the last inspection and the number of requirements and recommendations highlighted at this inspection. During this inspection four Immediate Requirement notices were issued relating to pre admission assessments/care plans/risk assessments, complaints/protection of vulnerable adults procedures, poor recruitment/induction and training and care staff working excessive hours without sufficient off duty time. A meeting was conducted on 3.2.06 between the Commission and the home’s registered manager, operations manager and operations director to discuss the findings of this inspection. The response from the registered manager and operations manager pertaining to the reasons for the home’s poor performance appeared very defensive. The registered manager, operations director and manager were advised that an application to vary the home’s registration would not be agreed at this time based on the home’s poor performance and findings from both inspection undertaken between 1.4.05 and 31.1.2006. What the service does well: Food provided to residents is very good. Residents are offered choice and the food is attractively presented and the quantity of food provided is appropriate. Several residents spoken with were very complimentary. The majority of residents spoken with stated that they liked living at Stambridge Meadows. Relatives spoken with were also very complimentary regarding the plush surroundings and care provided by care staff. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5 The home’s Statement of Purpose needs to be reviewed as it does not provide prospective residents with the information they need to make an informed choice about where to live. Records did not consistently evidence that residents have their needs assessed prior to admission. The registered person is unable to demonstrate the home’s capacity to meet resident’s needs. EVIDENCE: The home’s Statement of Purpose needs to be updated to reflect the home’s change of name from The Old Rectory to Stambridge Meadows and to reflect the change of registered provider. The registered person must ensure that a copy of the latest inspection report is available within the document (September 05). No Pre Admission Assessment was available on the day of inspection for one newly admitted resident (29.1.06) and it was unclear as to whether or not an assessment had been carried out prior to their admission. At a meeting held on 3.2.06 with the home’s registered manager, Operations Manager and Regional Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 9 Director, the inspector was advised that the pre admission assessment had been completed and was readily available. A copy of the assessment was shown to inspectors. Pre Admission Assessments were available for other residents, however it was unclear as to whether or not their representatives had visited the home prior to their member of families admission. On inspection of a random sample of staff training records, staff need training on issues related to the care and conditions of older people and mandatory training such as Manual Handling, Basic Food Hygiene, Basic First Aid, Infection Control and Health and Safety. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 11 The care planning processes within the home are very poor and it is unclear as to how care staff, have delivered quality care to residents and how their healthcare needs have been met. The home’s medication procedures and records were seen to be satisfactory. EVIDENCE: On inspection of seven individual care plans, care plans were not devised for the three newest residents to be admitted to Stambridge Meadows (nursing care residents). Dependency profiles were not completed for two of the newly admitted residents. One senior member of care staff requested to see one resident’s care plan, as they had not been on duty since this person’s admission and needed to know the persons care needs. The care plan was observed to be blank except for a tick depicting that the resident had a peg feed. Of the remaining four care plans, one was seen to be detailed and comprehensive evidencing the care/health needs of the resident. The three remaining care plans were relatively detailed, however additional information is required pertaining to their specific care needs and staffs interventions i.e. one care plan made reference to the residents poor communication needs, however Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 11 this did not detail how the resident finds it difficult to communicate or how care staff communicate with them. Formal assessments relating to falls, nutrition, pressure sores and urinary continence were not always completed or only partially completed, making the assessment tool invalid. Risk assessments were not devised for all areas of assessed risk i.e. one persons care plan made reference to them being at risk of falling out of bed, however no details were recorded relating to them being at risk of bed rails/entrapment, requiring a soft diet/weight loss, poor communication and having a catheter in place and the associated risks involved. Not all care plans/risk assessments had been reviewed in line with National Minimum Standards recommendations e.g. one residents care plan made reference to them sustaining a steady weight loss and that as a result they should be weighed weekly. There was no evidence to indicate that the resident had been weighed in line with her care plan or that the resident had been weighed every month. At the meeting on 3.2.06, the registered manager stated that monthly weight audits had not been transferred to individual files but were available. The monthly validation audit and regulation 26 report, for December 05, which was completed by the home’s Operations Manager, both detail that care plans are appropriate. Life Story’s were not completed for all residents, those that were completed were observed to be informative and detailed. Residents daily care records were inconsistently completed and did not always include evidence of staff’s interventions and were not written daily in some cases. Records relating to `turn charts` and `food/fluid intake` were not filed in a logical order i.e. date order and during the inspection it was difficult to decipher as to whether or not these elements had been undertaken and recorded accurately. The home’s medication policy and procedures were seen to require reviewing as these were dated 2001. Minor omissions were observed on resident’s medication administration records, whereby care staff had not signed the records to indicate that medication had been administered to and received by individual residents. Medication storage systems were observed to be appropriate at the time of the inspection. Records relating to the home’s controlled medication were seen to be appropriate. Throughout the inspection lounge areas were monitored to ensure staff deployment was appropriate for the numbers/needs of existing residents. On several occasions the main ground floor lounge by the reception area was left unattended and unsupervised. Inspectors were aware that one resident who resides within this lounge area is at risk of falls and there was physical evidence to indicate that she had recently experienced a fall, leaving her face extremely bruised. During those times when the lounge area was left unsupervised by care staff, the resident was seen trying to get up and walk out Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 12 of the lounge area with her walking frame. Several residents were heard to shout and to physically use their walking frames to block her exit out of the lounge area. This is unacceptable and places a number of residents at risk of falls/possible injury. The issue relating to deployment of staff was highlighted at the last inspection and remains of concern. On 3.2.06 the registered manager stated that the lounge areas should have been staffed, especially as one resident is receiving 1-1 support from care staff. This was not evident throughout the entire inspection (08.30 a.m.-19.15 p.m.) and no evidence of additional staff on duty was detailed within the staff roster. It was disappointing and of concern once again that call alarm facilities for residents were not always answered promptly i.e. one call alarm was unanswered for a period of 5 minutes. The care manager on duty was questioned as to why this had happened and reported that at the time three members of staff were trying to hoist one resident. The care plan for this person did not detail that three members of staff were required to provide manual handling procedures. One resident confirmed that on occasions they have had to wait a long time for care staff to attend to their needs. An Immediate Requirement was given to the care manager at the time of the inspection relating to a lack of pre admission assessments, no care plans/risk assessments being devised for the three newest residents. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Meals provided to residents are of an excellent quality. EVIDENCE: At the previous inspection to the home all standards pertaining to activities for residents were inspected and observed to meet the National Minimum Standards criteria. The home operates a four weekly menu. The menu’s are varied and offer residents choice at all mealtimes (breakfast, lunch and teatime). In addition to the planned menu’s/choices, residents are able to have alternatives i.e. omelette, soup, sandwiches etc. At midmorning and in the afternoon, residents are offered a choice of hot and cold drinks i.e. tea, coffee and two choices of fruit juice. The lunchtime meal offered to residents was observed to be appealing and of sufficient quantity. Resident’s comments relating to food provided at Stambridge Meadows were very complimentary. The tables were attractively laid and condiments were readily available. Residents have the choice of having their meals within the dining room or can have them in the privacy of their bedroom. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 14 Food and fluid intake charts for individual residents were once again muddled, disorganised and not filed in date order. In some cases records were incomplete and food/fluid were not recorded for individual residents. This is of concern as this was highlighted at the previous inspection to the home. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a complaints and protection of vulnerable adults policy and procedure, however it is evident that the registered manager does not know how to deal with issues effectively. Although procedures are in place, these do not protect residents from harm or possible abuse. EVIDENCE: The inspector was unable to decipher as to how many complaints had been received at the care home since the last inspection as records were muddled and in no logical order. Complaint records did not always include information pertaining to the nature of the investigation undertaken and outcomes. One complaint dated, 22.12.05 detailed that in October 05 there had been a lack of night staff on duty. The Commission for Social Care Inspection was not notified under Regulation 37 that staffing levels had fallen below those agreed by the previous registration authority or what action had been taken by the registered provider to address issues. Another complaint by a resident detailed that they were unhappy at night because of noise levels. It was unclear as to what action had been taken by the registered person to address the residents concerns. From inspection of a random selection of staff employment files, several letters were found depicting poor care practices by care staff and details of investigations undertaken by the registered manager i.e. On 16.1.06 one resident was found on their bedroom floor naked from the waist down and covered in a blanket. Additionally another resident was found in their bed with chairs against the bed and a wheelchair obstructing the doorway. The registered manager conducted an `in house` investigation and there was Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 16 evidence of witness statements taken etc. It is of concern that the registered manager did not refer the incidents under Protection of Vulnerable Adults (POVA) or that the Commission for Social Care Inspection was not notified. It is clearly evident from the examples above and from other records seen and photocopied on the day of inspection that the registered manager has failed to adopt robust procedures relating to the protection of vulnerable people. Records also detail that the registered manager has failed to deal with outcomes following disciplinary meetings i.e. the investigation highlighted that the member of care staff had not received an appropriate induction. No evidence was available to indicate that following the meeting the member of staff received an induction or received training pertaining to Manual Handling or POVA/Resident Welfare. At the meeting on 3.2.06 the registered manager advised inspectors that Resident Welfare training would be given to staff and this training would be provided by her as the homes trainer. The Commission is concerned that her own knowledge and understanding of procedures is poor and that staff within the home could receive inadequate training. Staff, were aware of the location of the complaints policy and procedure but not the Protection of Vulnerable Adults policy and procedure. No forms for staff to complete relating to the above were available. An Immediate Requirement notice was issued pertaining to the above. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home is well maintained and provides residents with a homely and very comfortable environment. Minor health and safety issues were highlighted pertaining to fire doors. EVIDENCE: The home is decorated to a high specification. All resident’s bedrooms are personalised and individualised. All areas of the home were observed to be clean, tidy and well maintained and odour free. Two relatives spoken with compared the premises to that of a 5 star hotel. Health and safety issues highlighted at the previous inspection were addressed. Fire doors were observed to be `wedged open` despite door guards being fitted. Staff advised the inspector that should fire alarms be activated the door wedges would be removed by care staff to allow doors to shut. The registered person must discuss these issues with the local fire department and confirmation of their decision must be forwarded to the Commission within 14 days of receiving this report. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 18 In the afternoon a number of residents bedrooms/en-suite facilities were observed to have no hand towels/face flannels available for residents use. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 It remains unclear as to whether or not staffing levels within the home were appropriate for the needs/numbers of residents. Recruitment procedures within the home do not protect residents. Staff training/lack of training does not meet the needs of residents and induction training for staff is poor. EVIDENCE: As highlighted at the last inspection, on inspection of staff rosters it was unclear and difficult to determine start and finish times for some staff and/or if sickness had been sufficiently covered. The deployment of staff between the ground and first floors was unclear and it was evident as previously highlighted that there were insufficient numbers of staff available to supervise the main ground floor lounge area and to ensure residents safety. It was evident from the staff rosters that some staff are working excessive hours i.e. 54-72 hours in any one week. Nine staff employment files were inspected. Several files evidenced not all records as required by regulation had been sought i.e. POVA 1st, no written references evident on one persons file, Criminal Record Bureau checks received after the employee had started employment, no proof of ID and employment histories not fully explored. Of those files inspected not all had a record of induction and for those newly appointed members of staff who had no previous care experience, inductions were poor and not appropriate. Rosters did not evidence those staff members receiving supervised shifts or being Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 20 Training files were not evident for all members of staff. Not all staff employed at the home have received mandatory training (Basic Food Hygiene, Manual Handling, Basic First Aid, Infection Control, Health and Safety, Residents Welfare and POVA). Gaps were evident in relation to specialist training i.e. diabetes, catheter care, Parkinson’s disease and other conditions related to those of older people. No staff records were available for agency staff utilised at the care home. In addition there was no written confirmation from the agency stating that all checks had been completed and these were satisfactory. An Immediate Requirement was issued to the home relating to the above. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36 and 38 It is evident from this inspection that residents are not benefiting from a well run home and that the registered manager/organisation has a lot of work to do to improve current standards and working practices for staff. EVIDENCE: As highlighted throughout this report, there is clear evidence to indicate that National Minimum Standards and requirements from the last inspection have not been addressed and that standards and requirements continue to slip. This failure has resulted in poor care provision for some individual resident’s, resident’s being placed at risk, poorly trained/recruited care staff, lack of communication between the organisation and the management of the home and a `blame culture` has arisen. Little or no evidence was available to indicate that care staff have received formal supervision on a regular basis. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 22 A number of records relating to health and safety were inspected i.e. employers liability certificate, fire alarms/fire extinguishers, hot water temperatures, COSHH risk assessments etc and seen to be satisfactory. The record of fire drills needs to include the names of all staff, who participate and the time of the drill. Certificates pertaining to the home’s passenger lift, gas and electrical safety installation and hoist servicing were not available. The registered provider must forward a copy of the above four outstanding certificates to the Commission within 7 days of receiving this report. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 1 2 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 X 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 X X X 1 X 2 Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard OP1 OP3 OP30OP4 Regulation 6(a) 14 18 (1)a & 18 (1)c Requirement Ensure the Statement of Purpose is kept under review. Ensure that all prospective residents are assessed prior to admission. Ensure that all staff at the care home undertake appropriate training to the work they perform and have the necessary skills and expertise to meet the specialist needs of residents. Ensure that comprehensive and detailed care plans are devised for all residents. Ensure that risks to residents are identified, assessed and detailed documentation is completed. Ensure that information relating to pressure sores (treatment and outcome) are recorded within resident’s care plans. Previous timescale of 01/01/06 not met. Ensure that the health and welfare of residents is promoted and residents are empowered to make decisions. Ensure that call alarms are DS0000015554.V279281.R01.S.doc Timescale for action 01/04/06 14/02/06 01/07/06 4. 5. 6. OP7 OP7 OP8 15(1) 13(4)(c) 17(1)(a), Sch 3 01/05/06 01/05/06 01/03/06 7. OP8 12(1)(2) 14/02/06 8. OP7 12(1)a & 14/02/06 Page 25 Stambridge Meadows Version 5.1 13(4)c answered promptly. Previous timescale of 14/10/05 not met Ensure that resident’s wishes and views are considered. This refers specifically to funeral arrangements and terminal care information being sought. Ensure that complaints are fully investigated detailing the complaint, investigation and outcome. Ensure that all staff and the manager receive training relating to adult abuse. Ensure that consultation takes place with the fire dept pertaining to fire doors being wedged open. The registered person must ensure that suitable arrangements are made for maintaining satisfactory standards of hygiene in the home and ensure that suitable arrangements are made for the disposal of general/clinical waste. Not inspected on this occasion Ensure that at all times care staff are working in the care home in such numbers for the health and welfare of residents. This refers specifically to the deployment staff within the home’s lounge areas and the staff rosters evidencing staff not completing their scheduled hours. Previous timescale of 14/10/05 not met The registered person must ensure that all records as required by regulation are sought for all members of staff. Previous timescale of 01/01/06 9. OP11 12(2) 01/05/06 10. OP16 22(3)(4) 01/03/06 11. 12. OP18 OP19 13(6) 23(2)(4) and (c)(i) 16(2)(j) & (K) 01/07/06 21/02/06 13. OP19 01/04/06 14. OP27 18(1)(a) 01/03/06 15. OP29 17 (2) &19 (1) 14/02/06 Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 26 16. OP36 18(2) not met The registered person must ensure that all staff receive supervision. Previous timescale of 01/01/06 not met Ensure that the manager of the home is competent and skilled to carry on the role of manager. Ensure that equipment at the home is maintained in good working order. Refers to lift, gas, electrical and hoist certificates. 01/01/06 17. 18. OP32OP31 OP38 10(1) 23(2)(c) 01/03/06 21/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP15 OP19 OP28 OP30 Good Practice Recommendations Nutritional records should not be muddled and should be completed for all residents. Ensure that hand towels and flannels are available for residents. 50 of care staff achieve NVQ Level 2 or equivalent All newly appointed members of staff should receive an induction according to their qualifications and previous experience. Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stambridge Meadows DS0000015554.V279281.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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